CHAPTER 32 MEDICAL MISSIONS: The Mechnics Stepben J. Miller, DPM Our world is filled with people who hve insurmountble obstcles to freeing them from the grip of poverty nd destitution, not the lest of which is ccess to helthcre. Relince on EJovernments to institute soir-rtions to the problems of the poor is frught with obstcles such s lck of resollrces, indifference by the ruling regime, grft nd corruption nd sometimes frnk politicl obstruction. Devstting humn misery cn remin withor:t relief s governments poncler something s mundne s definition.' Medicl missions collectively comprise one method of helping to llevite poverty nd suffering. Their gol is to bring skilled people who cre into contct with people who need. Nevefiheless, there re critics who feel tht medici missions provicle substndrd cre nd squnder millions of dollrs tht could be put to better use by 1oc1 uthorities.' Sti1l others rgue tht only the best trined specilists should provide such cre in the third wor1d.3 To counter these rguments, if we were to wit until such utopin conditions cotiid be estblished, thousnds of people would continlre to suffer unided. When tem clrmticlly chnges the life of even one chi1d, one individul, then the members hve collectively contributed to better worlcl. It is seen in the smiles of grtitude from the recipients nd their fmilies obsetwed on every mission. Just like the "strfish story." VOLUNTEERS experience together, n experience tht involved generosity, hrdship, cmrderie, temwork nd insight into nother culture. Desirble chrcteristics hve been listed to help recruit relible volunteers to chieve successful medicl missions (Tb1e 1). A volunteer must demonstrte the right commitment.i Unfortuntely, not ll people volunteer for the most ltruistic of resons. Selfish motives of ny individul cn threten ny opertion, but they cn devstte medicl mission. THE INMITATION Although medicl mission cn be offerecl to ttend to ny needy people, it rel1y must end up being response to n invittion. It should never be foisted upon nother people, no mtter how destituie. Their dignity should lwys be respected. Idelly, one or more ofgnizers cn mke n dvnce scouting trip to the host collntry to ssess the needs nd resources vilble. This type of on-site contct is invluble s it cn firm up n invittion nd provide vluble informtion for the pretrip preprtion. There re mny sponsoring orgnizlions tht function s logistics coordintors, communiction centers nd combined resources for informtion, Tble I People volunteer to pfiicipte in medicl missions for vriety of resons, the most common being to express their compssion for the less fofir-rnte. It tkes courge nd sense of commitment to volunteer. It not only costs time nd money but it involves exposure to the rw side of poverty s well s vrious leve1s of risk. On the positive side, seruing on medicl mission tem leves ech volunteer with profound sense of ccomplishment nd the grtifiction of hving mde smll difference in the lives of few unfofiunte fellou,' humn Lreings. There is n indelible bond between the tem members s result of unique VALUES TTIAT MOTTVATE STAFF AND VOLUNTEERS FOR HEALING THE CHILDREN love of children fespect for people ppliction of best medicl nd ltusiness prctices people working together in tems collbortion with other orgniztions hope, optimism nd fith in God the bility of one person to mke difference the pssionte commitment to tke ction.
162 CHAPTER 32 contcts nd coordintion. They re invh-rble for the support tht they cn provide. A sponsoring orgniztion is impofint for logistics nd funneling finncil support, s well s resource of experience nd volunteer trining. It cn be ny one of the mny nonprofit orgniztions set up to orgntze nd implement medicl missions nd to bring ntionls from the host country stteside for specilized tretment. Representtive exmples of such orgniztions re seen in Tble 2. They my lso be service clubs such s Rotry, Kiwnis or Soroptomists, church entities or other NGO's. II{E TEAM A medicl mission consists of tem of helth cre volunteers trveling usully to nother collntry to provide medicl services to the indigent t the invittion of the host entity in tht country. Being invited is essentil to the cceptnce of the good will intended by the proposed mission. The vrious entities tht my invite nd be integrtecl into the coordintion nd implementtion of the project include locl foundtions, hospitls, clinics, orphnges, relip;ious orgniztions, nd government gencies. A successfi-il medicl mission requires relible sponsoring orgniztion, meticulous plnning, mutully supportive tem of dedicted volunteers. strong tem leder nd responsive tem dministrtor, continuing coordintion with Tble2 the host entity, nd endless communiction nd coopertion mongst the orgniztions supporting the mission ncl those involved in crrying it out. A tem my vry from n individul doctor or dentist or other provider nd n ssistnt who incorporte locl resources5 (e.g., brigd) to complete entourge of surgeons nd support personnel who trnspofi ll their equipment nd supplies. (Tble 3) THE MISSION The min purpose of the medicl mission is to provide specilized serwices to the needy not vilble in their country or due to their circumstnces, withor-rt chrge. The second gol is eduction of the locl rnedicl ncl socil support personnel. Involving nurses nd doctors in s much of the evlutions, surgery nd tfetment s possible extends the benefits of the mission nd ensllres follow-up cre, besides engendering good-will. Arrnging clequte postopertive cre is essentil. The third oblective of the mission is to expose the tem to the loc1 culture nd customs nd, t the sme time, deliver supplies, equipment nd other gifts to improve cre delivered loclly. The durtion of medicl mission vries from one week to one or more months to the estlrlishment of more durble mission tht provides the core set-up to cycle volunteer providers on regulr bsis. One week is populr becuse it fits into the usul western work/vction schedule ncl is the most ffordble for most volunteers. It is thought to be iclel for medicl mission SPONSORING VOLUNTEER ORGANIZATIONS Heiing the Children (HTC) Esperng Interplst Rotplst Interntionl Orthopedics Overses (AAOS) Helth Volunteers Overses Outrech & Eduction Funcl (AOFAS) Opertion Condor - Peru Doctors of the Vorld Doc'tors for the Poor Centrl Asi Institute \X/isdom in Action Northwest Medicl Tems Thble 3 A TYPICAL FOOT SURGERY MEDICAL MISSION TEAM* 1 Tem T.ecler 1 Tem Adminstrtor 2-4 Surleon(s) 2-4 Anesthesiologists/Nurse Anesthetists 7-2 Peditricins/Fmily Prctitioners 2 Scrub Nurses,/Surgicl Scn-rb Techniciens 2 Circr-rlting Nurses 2 PACU Nurses 1 Logistics Coordintor 1 IT Processor 1-4 Trnsltors t'assumes ctccess to t leotst two operting totbles
CHAPTER 32 t63 to go bck to the sme loction regulrly so s to provide some mesure of cre continuity. However, greter impct is rclized when meclicl volunteers commit to yer or more in the sme re.i Achieving successful mission lso involves the coopertion of mny suppofi orgniztictns nd other entities: government gencies, other NGO's, nonprofit orgniztions in the host country, service orgniztions n'ith interntionl brnches, nd corporte donors. As long s one is not too intrusive or presllmptuous in his or her pproch corporte donors cn be surprisingly generous. This vluble reltionship should never be bused. It tkes mny people from the donor country ncl the host country working together to orgnize vible medicl mission. A pretrip meetinl or two of s mny tem members s possible is highly recomrnended. It set.lres s time to focus on the gols of the mission, rer.iew everyone's ro1es, check off supply nd equipment lists, pck them nd get preview of the cuiture of the host country. Ech prt of the tem: nesthesi, sllrgery, surgicl ssistnts nd medicl re responsible for ssembling their needed sr-rpplies nd equipment (Tble 4). Gret cre must be tken to keep the bgs nd boxes within the iriine weight nd dimension guiclelines. It is importnt for every tem member to crry/ their shre both to nd from the mission. TYPICAL ONE-WEEK MISSION After months of orgnrztion nd ssemtrly of eqr-ripment nd supplies, medici mission idelly ssembles t one US exit irport to fly together to destintion irport ner where the medicl mission is to tke plce. On zrrrivl, it is essentil tht ll documenttion is in order to cler locl irnmigrtion ncl customs. The more cletiled the orgniztion, the less likely tht there will be people nd luggge detined by the uthorities. Hving lists of the contents of ech bg or box inside, outside nd in seprte folder cn help decrese the need for officils to serch them. Once ll tem mernbers hve clered immigrtion nd cllstoms, prerrnged grouncltrnsporttion tkes people nd bggge to their ccommodtion. This my be fbr the mission itself or fbr n overnight sty so s to be trnsported to more clistnt loction for the mission the next dv. Sturdy is good time for the tem to ssemble in the evening for dinner to get zrcquinted nd socilize nd hopefully meet some of the host country personnel. Perhps, there is even time to tour some of the fcilities tht re being mde vilble. Sundy is usully the dy when the potentil ptients preselected by the hosts re screened by the surlleons nd then by the cloctot's responsible for medicl mngement nd nesthesi. Preopertive screening for nesthesizr is importnt s it helps minimize the potentil complictions for the chiidren.6 This is very demnding session tht cn be quite hectic. So, it tkes detiled orgniztion ncl coordintion. Records nd dignostic films from the hosts re mde vilble nd kept with the record fbr ech ptient. Trnsltors need to be redily Tble 4 EQUIPMENT AND SUPPLIES FOR A MEDICAL MISSION Anesthesi mch-ines Aneslhesi monitiors Anesthesi supplies nd drugs Surgicl gowns (pre-sterilized) Drpe nd strter pcks Msks, gloves, shoe covers, cps Surgicl instrument sets Antiseptics nd prep sets Miscellneous surgicl instruments (to supplement the sets) Single instruments Internl fixtion instruments nd implnts Externl fixtion equipment (optionl) Power instrument sets nd ttchments Cutery units nd hndpieces Portble suction Tourniquets PACU monitors nd equipment Drugs for nlgesi, ntibiotics, nti-inflmmtories, nti-emetics Sr-rtures Dressing mterils Csting mterils Cst cutter First id kit Toys nd gifts
164 CHAPTER 32 vilble to ll sttions involved in this screening nd informtion ssembly process. An informtion record is estblishecl for ech child selected for surgery, preferbly with the id of lptop computer. A Polroid or digitl photo should be tken of the ptient nd ttched to the record. Informtion forms nd history nd physicl forms s well s preopertive nd postopertive instructions shoulcl be prepred in both English nd the locl lnguge prior to the mission. Hving computer printer long is invluble for mking lst minute forms, printing photos nd mking signs. The computer cn store c1t, forms, Iists nd photos. It cn lso be used for internet ctivity. While the doctors re screening the ptients the OR crew is tken to the operzrting fcility to set up the opertin5l rooms, orgnize the supplies nd meet the locl medicl stff. They must quickly ssess the resources vilble nd rrnge how the tem's resource's cn be used to compliment those vilble 1oclly. At the end of the screening, the doctors nd other tem members meet to estblish the surgery schedule for the week. The computer is gret resource for this but it cn be done on pper if necessry. The tem leder is responsible for ssigning the surgeons nd other supportinp4 tem members to the individul ptient's tretment. Sometimes, non-surgicl cre is prescribed, such s csting or-rt flexible clubfoot deformity, nd the loc1 medicl personnel re involved. Surgery to correct the children's deformities is usully performed Mondy through Fridy. Ech dy strts with rounds in the morning on the prevlous dy's surgicl cses nd prepring the children for the schedule of the dy. This requires lot of coordintion, especilly first thing in the morning nd cluring cse turnovers. It is not unusul for two operzrting tbles to be ctive in the sme operting theter. A good PACU stff is nother essentil. The children usully sty one or two nights before being dischrged with written instructions, mediction nd n ppointment for follow-up cre. It is importnt to invite the locl mediczrl stff to pfiicipte in the errlutions, surgicl nd hospitl cre nd prepre them for postopertive mngement. Even before ny invittion to send medicl mission tem, loc1 orthopedic slrrgeon or trined physicin must be identified s greeing to provide the cre postopertively. On Sturdy morning, the finl hospitl rounds re completed with cre for the remining ptients being trnsferred to the 1ocl stff. Then the tem heds either directly home or to n re town or villge of interest for cly nd night to unwind before flying Lrck to ech member's country. LOWER EXTREMITY PATHOLOGY The rnge nd vriety of pthology encounterecl on meclicl missions drws on every ollnce of one's trining ncl experience s well s cretivity ncl resourcefulness. Mny congenitl deformities, neurologicl deficits nd inherited disorders re routinely encounterecl s well s the sequelle from injuries due to mines, burns nd trum. A list of typicl deformities nd disorders encolrnterecl on medicl missions is seen in Tble 5. Deformity repirs, revisions ncl reconstrllctions entil vriety of releses, rthrodeses, osteotomies, tendon trnsfers, ncl mputtions, ol revisions (Figures 7-72). They often require tem consulttion, decision-mking nd surgery prticiption. Blinging one or two reference textbooks cn be extremeiy heipful but certinly dcls to the luggge weight. EPILOGUE Tem members must be forewrned bor-it the retlrrn home. Even fter short week wy. the intensity of lengthy trvel, working in dr.erse conditions immersed in poverty nd experiencing Iimited resources) person's emotionl nd physicl cpcity cn be firly exhusted. There is quite culture shock with the return home nd twinge of guilt cn set in when confronted with the bundnce. However, the f'eeling of ccomplishment tht nturlly permetes one's whole being following mission fr outweighs the feelings of indequcy t not being ble to solve ll the problems. Contributing to improving so much s one child's life brings sense of joy nd fi-r1fillment tht is more thn enough rewrd for committing to the medicl mission.''o
CHAPTER 32 t65 Thble 5 TYPICAI PATHOLOGY AND PROCEDURES ENCOUNTERED ON MEDICAL MISSIONS Clr-rbfoot CongenitrI Mrlfonntions Verticl Tlus Artl-rrogryphosis Cerebr'.rl Plsy Post Polio \erlrologit l Delicits AmpLlttions/Revisions Frcture Mgt/Revision Burn Scr Revision Figurc 1. Polydct,vlv fcct Figure 2. Po11.6lx61u1u post sr.l1'!ijcl reduction igrire I. Anlpllt:ltion slutnp clcfbrmitv preventing ttse of prosthesis. :unplrt:rtiorl sturnp rcv jsiot-l Figr-rre 5. Post polio c:rvoeqr:inrts clefbrn'ritv
166 CHAPTER 32 Figure 6. Post-polio flccicl pri.vsis. Figure 7. Cerebrl plsy CONtfACtLII'CS, pticnt n,ith Figule 8. Posrsurgic:rl relese ol Achillcs ml hntstring conrrcrlires. Trigule!. Rcsistnt clubfbot in 9-month olcl nrlnt Figure 10. lncisiotr mrkccl fbr posteromeclil relesc of clubfirot clefirrrifr'.
CHAPTER 32 167 Figurc 11. Post surgicl reduction of clr.rbfbot cleformitv Figure 12. Neglectecl clubfbot dcformity REFERENCES I. Le:rning J. Digr-rosing genocicle-the Cse of Drfur. N Ertg J llerl 2004:351:735-8. DrLpuis CC. Ilumnjtrin missions in the Third -i[orlcl: polite clissent. P/sl Reconstr Stug 204:773:133-i. Mrrllikcn JR. The cirrrging fccs of children with cleft lip ncl pe\^te. N Eng J ller:l. 2004357:745 7. Crnrner HH. Volunteer r'vork-logistics first. N Eng J lled 2005:353:7511-4. 6. 8. \(io1flrerg AJ. Yolunteering ovcrses-lcssons from surgicl lrrigdes. N ErtgJ Med 2006;3541443-5. Fishcr QA, Nichols D. Stewrt FC, et :r1. Assessing peclitric nesthesi prctices for voluntecr medicl sen'ices brod. Anestb esioktg.y 200 I ;95 :7375 22. Scrnton PE, Gonclring W-. Shields NN, et l. Specil Repot: The 20OJ Orthoped:ic Eduction Foundtion's o\rerses missiorl to Vietnm. Foot Ankle Intl 2004;25:772-9. Scrzlnton PE, Veith RG, Thom:rs, R, et l. Specil rcport: the 200'1 Orthopedic Ecluction Founcltion's ovcrses rnission to Vietnm. Foot Ankle Intl2001;25:903-1.